Provider Demographics
NPI:1174891709
Name:PAYNE, IRINA V (APN)
Entity type:Individual
Prefix:MRS
First Name:IRINA
Middle Name:V
Last Name:PAYNE
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:232 CEDAR GROVE LN
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:NJ
Mailing Address - Zip Code:08873-5209
Mailing Address - Country:US
Mailing Address - Phone:732-873-8978
Mailing Address - Fax:
Practice Address - Street 1:232 CEDAR GROVE LN
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:NJ
Practice Address - Zip Code:08873-5209
Practice Address - Country:US
Practice Address - Phone:732-873-8978
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-09
Last Update Date:2013-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00350600363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0305391Medicaid
NJ0305391Medicaid